katm0 1,652 Views
Joined Mar 5, '11.
Posts: 59 (25% Liked)
At this new facility, they are very short...just "SVD female" then "placenta delivered".
I was trained to be more detail from my old facility.... "Spontaneous vaginal delivery of viable female/male.... Stimulated and dried with towel... Vigorous cry...quick pinkening...cord clamped and cut. Skin to skin with mom......(or to preheated radiant warmer for assessments, meds given and id bands applied x2 or wrappedx2 with hat on to mom).
As far as placenta, "placenta delievered. Pitocin started as ordered."
Am Im charting too much? What do you chart? Please share.
Hmm...I agree that seems odd. I am all for detailed charting. Does everyone at your new facility chart this way or just a few people are this brief? I write the exact same note as you do, something along the lines of "SVD of live female/male infant, bulb suction to mouth and nose on perineum, dried and stimulated with towel on abdomen. Alert, quick pinkening, spontaneous lusty cry (if applicable), moving all extremities strongly and equally, FHR 150s (or whatever number i get as soon as I check) with regular rhythm. To radiant warmer for assessment." Our newborn admission form has separate areas from the small narrative box to chart medications, apgars and a thorough assessment. All of the placenta charting is done on mom's labor and delivery form. We also chart mom's BP right after baby is delivered and then again a couple minutes after the placenta delivers.
Pitocin is routinly given post partum to OB patients to initiate and strengthen uterine cramping to avoid excessive bleeding. If she is on mag the uterus is going to be more relaxed and not contract as it should post partum, leading to increased bleeding. Essentially the 2 are going to battle it out. The next route to avoid fluid overload (since high doses and prolonged use can cause fluid overload and fliud intoxication and then additional swelling in the internal organs - ie brain and the flesh), while maintaining a firm uterus with MINIMAL vaginal flow (that would be the goal, NOT moderate) would be a stronger med that is used in post partum hemorrhage - the commonly used ones would be methergine (usually injectable initially and then orally for a period of time), hemabate or cytotec (usually 800-1000 mg transrecatally for bleeding). methergine in this case was a very poor choice since it is contraindicated in high blood pressure patient. the better choice would be cytotec.
mag sulfate is NOT used to lower blood pressure - common misconception. All it is meant to do is prevent siezures (ie raise the siezure thresh hold to a safer level) by relaxing muscles. often times a side effect of this relaxation is lowered BP, but often times in severe Pre-e patients that is not even the case. The doctor should have ordered a medication specifically for lowering BP in addition to the mag. we often use hydralazine for that. while it is true that one does not want to lower the blood pressure quickly for risk of siezure, the mag sulfate, once on board, minimizes that risk. The woman is also at risk for a stroke and one needs to prevent both siezures and stroke. Remember the reason that she is at risk for the siezures is swelling in the brain, not nessecarily the blood pressure itself. the blood pressure being elevate (and often the pulse as well) puts one a a very high risk of stroke. both need to be carefully managed. by what you describe, I would be very concerned for this patients well-being.
As a side note, I myself was victim of post partum pre-e. My BP (the last time I saw it on the ICU monitors) was 189/110 and pulse of 180s. This developed in 12 hours. That is very typical for the really severe cases. Both in my case and the truely scarey and severe cases over the years, the patients were "normal" (BP, pulse and labs WNL) and 12 hours later, having siezures. In my case the BP started to climb at 3 weeks PP and within 3 hours I started getting pixilated vision and 5 min later I was blind (due to the swelling in the brain compressing the optic nerves) Within a few hours of my blindness, I was having siezures and a mild stroke. These women are VERY high risk and one should be vigilant at all times for subtle signs that it is worsening. I did end up ventilated for 2 days because the medications used to manage my siezures and BP caused me to stop breathing (another unfortunate side effect of this sort of management). In the case of your patient on mag sulfate, there should be calcium gluconate at the bedside in the event of mag toxicity (can cause cardiac arrest). This also happens VERY fast and everyone is susseptable to toxicity at different doses and time frames and it seems to have no baring on patient size, but rather that level of liver compromise from pre-e/ HELPP syndrome. In this case one should be assessing hourly for signs of mag toxicity and worsening pre-e/siezures/stroke.
I remember those days! Well, when i first meet a patient I start a conversation about how they feel generally. I take a set of vitals to assess for HTN or hypotension if they have en epidural- with that i will assess for headache or blurry vision (think Pre-eclampsia and yoou will prob. alreadyy know if the patient has been Dx with that before you go into the room). Take a TEMP! very important. if her water is broken the risk of infection to baby increases the longer she is in labor. I monitor them for ctx in correspondence with the external (or internal) fetal monitor to make sure I am picking up her ctx. I monitor the fetal heart rate. If her membranes are ruptured I check the underpads for color, odor etc. I check for edema from head to toe. The assessment is different than a med/surg patient but I think I covered everything I do on my initial assessment. Just be sure to look over the chart for her history, diagnosis and current status as far as gestation, start of labor, induction, augmentation, risk factors, allergies, rupture of membranes, labwork etc.
Good luck! I LOVED my L&D rotation hence why i went straight for it after I graduated =)
I am a new nurse in Labor and Delivery as well - it is overwhelming and scary and I am not ready to be off orientation in less than a month. BUT -- just remember that most everyone feels scared starting off.
Some tips that I have from experience and asking my coworkers...
1) Write down everything you learn/patient requests so you don't forget. Keep a notepad in your pocket.
2) If your floor does not provide them already, obtain or create "cheat sheets" for different situations you will run into at work. For example, I have C-section, induction, vaginal delivery and epidural check lists that I keep in my pocket so that I have access to what I need to do in the correct order. After a while you won't need the check list.
3) Volunteer to start IVs, perform vaginal exams or to practice skills on different patients that you might need some work on during your orientation.
4) ASK QUESTIONS. No matter how stupid it may seem.
5) Expect the unexpected. Every patient's labor is different and no one follows the same path, regardless if they are nulliparas or multiparas.
6) Do not take your eyes off of the FM strip unless someone is watching it for you while you are involved in someone else.
7) Review the patient's history in the beginning - prenatals, lab values, problems, allergies, blood type etc so that you can make an appropriate plan of care for the patient.
8) Document carefully and CYA (cover your a**). For example, If a patient refuses something, document what they said and what you did or said. They can come back with a lawsuit 10 years later and you will have the documentation that clearly states that happened.
This is all I can think of for now. Good luck!
UPDATED BASED ON SUGGESTIONS:
(oh i forgot to mention this is the L&D dept of same hospital, i am already an employee of the company, i just want to consider a tx to that dept)
I am writing in reference to your RN position listed on xxx's website for the full time Labor and Delivery RN, for the shift of 7a-7p. I am extremely interested in becoming a member of your team.
I think I would make a wonderful addition to your nursing staff. As you can see in my resume, I am a May 2005 nursing school graduate and have worked in the cardiac surgery progressive care unit at xxx ever since. Although this is not obstetrical in nature, I believe that my experiences here will qualify me for this position.
Working in a fast paced unit, I have learned to adapt quickly, make quick decisions, manage busy patients, do extensive patient and family teaching, work with patients who have the ability to decompensate quickly, all of which I think would also be applicable in the obstetrical setting.
I am a quick learner, enjoy learning new things on the job, do not shy away from difficult assignments, and have an affinity for relating to patients and their families.
I have always wanted to work in labor and delivery, since my rotation through your L&D department in nursing school, because your department was very educational, your nurses professional, and I felt it would be an excellent environment in which to work and to learn. That clinical rotation sparked that desire to be an OB nurse.
If you hire me, I will dedicate myself to learning all I can, and working hard to maintain the high standards you set for your unit.
I have already applied through xxx's website, but I wanted to introduce myself as a potential candidate. I hope to hear from you soon to set up an interview. Thank you for your time and consideration.
Since the economy went downhill and facilities started hiring seasoned nurses returning from retirement, and housewife nurses that had a husband layed off, etc. the fight for your desired position has intensified. You have to be at the top of your game in this very competitive job market.
I have spoken with many other hiring entities about what they look for in a resume, cover letter, and application. What are assets? What are deal breakers? What catches your eyes? What can a new nurse with no experience do to be considered if anything? What about the cliche: If I never get a job, I can't get considered for lack of experience? What are the bare minimums you want in a resume? What makes a resume, cover letter, or application pop out? The following are some tips and suggestions for those who are struggling with the hiring process.
The Resume (Should be one page front only for new grads)
There are so many opinions as to using the "Objective" or not. I personally always have, and have never applied for a position I didn't get yet (blessing/luck possibly). Use every line, every bit of your resume to scream, "Hire me!" I usually word it this way: "To obtain a position at "whatever facility" serving the patients of "region served," with competent, efficient, holistic, and indicated care within the scope of (RN, LPN, CNA, SNA, PCT) and with in the policies and procedures of (institution) to provide the best possible outcome for the patients in my care.
This shows your desire to "serve." It shows you took the time to research the area served by the institution, and their possible needs. It shows interest in the facility you are applying for. It is the first statement that you will do everything in your "scope of practice" and with-in "policy and procedure" and a heart of "SERVICE," not a "job" or "position," and denotes "drive." It also shows you wish to put SAFE PRACTICE FIRST. That you will not compromise your efforts out of your scope, and you will do everything in your power to advocate for your patients protection, well-being, and successful OUTCOME. It also takes OWNERSHIP of their VISION. Know your applicant facility's "Vision" so you can include it in your writings, or "mirror it."
The Education and Work Experience lines are the least customizable. Just be sure to get the correct dates and locations on this part. They will do a background check on these, and it could possibly be checked in HR before sent to your hiring Nurse Manager or Superior. THIS IS RARE. But it does happen. They could possibly also use this information as contact or referral. So you'd be slicker to leave off a negative experience facility than to put an incorrect date or falsify it. I have always just been honest here- they can smell a difference
There shouldn't be large inactive times in your Employment which should cover at least the last 5 years(sometimes up to 7). It really doesn't matter what age you started work, but you should be able to account for your time in-between positions. (Time off work for schooling is totally ok. I worked through school full time, but if you didn't, in denoting times, if school causes a >than 2 month absence of work history, just put a parenthesis in the work history to explain. (Attended Associate Degree Nursing Program 2001-2003 while unemployed).
If you must place large amounts of time between work experience, and you do make it to the interview - DO NOT LEAVE WITHOUT EXPLAINING THIS. Greater than 2 months is usually a red flag. They will not continue consideration without a good excuse (sick child, homemaking, displacement, family tragedy, etc), just address it.
Add Specific Examples. If there is any "Magic" in this, here it is! This is your chance to THRIVE. Many HR Reps I have spoke to ONLY read this line first in pooling candidates. They know as many threads have pointed out that you meet "minimum job requirements," but this is your chance to STAND OUT!
This is SO IMPORTANT. What sets you apart from the herd? Examples of stand-out statements:
I am a May 2012 graduate with my BSN. I looked ALL over Cali, even rural areas and nothing. Not one call, interview, anything. I started looking in Texas, and received 5 calls offering interviews. I was offered a position 20 minutes after one of my phone interviews. It is in Midland/Odessa area, so smaller town (about 200,000 people in the area), mid sized hospital (about 340 beds) and they are the only trauma center in the area- plus they are going to train me in the ICU!! Which is almost unheard of here for a new grad. Plan on getting my 2 years experience and moving back to Cali! If you can move for a bit, I would say DO it! Dont waste your time sitting around Cali when you could be getting your experience elsewhere and moving back in 2 years! Best of luck to you all- it is so tough out there, and I know exactly how discouraging it is to have worked so hard and to be rejected so many times.
Shuubie-WOW! You are a superstar if you are already getting the hang of things after only a month in the OR! Good for you!
It sounds like you are doing all of the right things. Asking questions is SO important. Sometimes (in my experience, MOST of the time) the pref cards are not exactly up to date. Keep a small notebook with you and divide into specialties like Neuro, General, Ortho, Vascular, GYN, Peds and then further subdivide into each doc on the service. I use the little stick on tabs-you can get them at Target or Staples. I write the most common surgical procedures at the top of the page and then list out what is needed. Example:
Under the General Tab, Under Dr. K:
Pager # xxx-xxxx
MD ID # xxxxxxx
Gloves 8.5 Biogel/8.0 Micro
Uses only XL LP gown
Only uses OSI flat top bed for lap chole cases. Page X-ray at beginning of case.
*likes classical music
Instruments to open:
ABD extras set
Lab Chole set
Endolock clip appliers
Instruments to have available only:
Dr. K extras
Lap chole pack
1 5mm bladeless trocar
2 5mm sleeves
Endo irrigation set
Cholangiogram set available only
0 Vicryl on a UR-6 needle
2-0 Vicryl SH x2
4-0 Monocryl PS-2
OSI flat top with full length gel pad
Pillow under knees
Foam at heels
0.25% Bupivicaine plain for trocar sites
Ancef 1 or 2mg prior to incision
NACL for irrigation
Omnipaque available only
Always uses a foley
Bovie at 30/30
Will always send specimen to path for gross only
Page him as soon as the pt arrives in the room
Call for next patient as soon as specimen is out
This is just an example of what I typically write for each surgeon. I will write additional notes for surgeons who are picky so that I don't have to ask them over and over again what kind of positioning they want before a case. There are a few surgeons that want weird positioning equipment (like a Kerlix suspended from an IV pole to prep a shoulder), and it helps me to remember when I write it in my book.
I am happy that you are finding your niche in the OR. It really is a great place to work. If you find that you are behind the 8-ball for big cases, try to see if you can get to work a little early to set up. Keep asking questions!
Good luck to you!
I graduated in May 2010 from a college in Georgia, and I moved to Orange County a few days after graduation. I didn't go to school in California, did not yet have CA endorsement (had a Georgia RN), and knew no RNs in the area, and had no clue where to start looking, yet I managed to find a job by June 2010. Here's what I recommend:
Think of where you would like to work (particular unit, ie: Med Surg, Tele, Oncology, ICU, ER, etc) and target your resume and skills toward that field.
For example, I always knew I wanted to work in ICU, so I did the following: (And I was hired in ICU)
-Basic Wound Care (just a one day class)
-IV Starts/Blood Draws (another one day class)
-Joined ANA (American Nurses Assoc)
-Joined AACN (American Assoc of Critical Care Nurses)
-Joined ENA (Emergency Nurses' Assoc)
1) I didn't really waste my time applying to countless new grad programs for several reasons. One, I didn't go to school here. Two, I had NO connections (these days, it IS who you know). Three, THOUSANDS of new grads who went to school here were applying, some of whom had probably even done clinicals at those hospitals and therefore had connections.
2) I went where the crowd of new grads didn't go: Community Hospitals (200 beds or less). I called those hospitals (direct number), asked to speak to the unit manager of (insert floor here). I did not immediately blurt out that I was a new grad. I would instead discuss my certifications, goals (MSN, CCRN, etc), and skills. Inevitably, the question of how much experience I had would arise. I would answer honestly. I got interviews that way.
I interviewed for one ER job and one ICU job. I chose the ICU job. Although I work for a local community hospital, I went through an awesome residency. They supported me, gave me an awesome preceptor, and told me to take as much time as I wanted. They also agreed to pay for any education classes I wanted to take, such as a Critical Care Course, etc. Although they told me it would probably take me 3 months of orientation, they told me I could take as much time as I wanted. It is an amazing opportunity. Having worked almost a year for them, I have been oriented in ER as well as Tele so I periodically float to both those floors, so it is great experience. Being a small hospital, there is a small number of employees and therefore I have a HUGE opportunity to advance very quickly if I want. I also work beside some nurses who work PD or PT and some FT at other huge hospitals, so now if I wanted to, I could work for a big hospital. Also, because this is a small hospital and our care is limited, my residency was not a really overwhelming experience. I got the basic skills to build on in order to be comfortable without going through sensory overload. BEST OF ALL, the hospital is THREE MILES from my house! No freeways!
My particular hospital has hired numerous new grads in different areas in the hospital, though they don't advertise a formal new grad program. Many community hospitals operate this way.
KNOWING WHAT I KNOW NOW, HERE IS WHAT I'D RECOMMEND:
1) Join your local AACN, ENA, or other specialty area, and ATTEND A CHAPTER MEETING. You WILL meet people
2) Attend a Magnet meeting
3) Take a lot of classes (nurses attend those, and it's a great way to network!)
4) I have not had any luck applying online to job applications (this is just my experience)
5) I did have luck calling floors directly
6) If there is not an opening currently, KEEP CALLING the unit director every week. Send a thank-you card. Send a Holiday card.
I still actively follow these new grad threads because I feel your pain. Though I was fortunate to not spend months and months looking for jobs, I understand how hard it is.
I hope this helps someone.
I had applied to the new grad program at UCSD earlier in summer and never got a call like many of us but noticed they weren't interviewing in the oncology department even though it was initial listed as a department with openings for new grad. I figured the 43 internals who applied for the 40 positions all got the jobs. Then I got a call last week for an interview Friday, and Monday a call offering me a job in oncology at Thornton. I guess you never know in this crazy job hunt. They said they considered the work I had been doing at a hospital since I graduated last year so anything you can do while you are waiting for that "perfect" job counts. Good Luck to everyone out there and thanks for the support on this site. Don't give up hope.....
I just wanted to share what happened to me today - a miracle!!! I graduated nursing school in May 2011, passed my NCLEX on June 19 and interviewed for my dream job on June 20th. For the next few weeks, I along with numerous interviewees shared our anxiety on an allnurses thread. As July 2nd approached, I started reading that some of my fellow interviewees were getting job offers. My phone was quiet. The following week I got the dreaded rejection email and I was devasted! I cried because I knew that the outlook for me in the next couple of months could be grim. I had gotten an amazing opportunity to interview at an amazing facility in the unit I wanted and I had blown it!
Out of the blue I got a phone call today offering me the position! A true miracle! Someone had to drop out of the program and my name was next in line! What are the chances? I prayed like I've never prayed before for this job & I guess today I got my answer! My advice to my fellow new grads is not to get discouraged. I read so many posts from frustrated new grads and I definitely feel your pain, but please don't give up. There are jobs out there I promise. About 5 or 6 other newly graduated classmates have also gotten jobs in other facilities. :redpinkhe
I graduated last December, got licensed this Feb., got a job offer this week.
I handed my application or resume into the person in charge of doing the hiring in PERSON! I never let them take it and leave it for them to read later. Even if it meant I had to return to the place several times. I also a 30 second spiel to say about why I wanted to work there that showed my enthusiasm and personality.
Yup.... that's how I did it. I filled out almost 100 online applications, not one interview. About half the places I walked into in person gave me interviews and after a few weeks I had a job offer.
I was asked a couple. One interview they started by asking me where I saw myself in 5 years (always a scary question) I didn't want to lock myself into the job I was applying for so I said I was really interested in the learning experience and elaborated on that. They also asked me what I would do if I was put in a position of supervision or management of LPNs and CNAs. I said I would handle it professionally, I wouldn't hold my power over anyone's head, communicate effectively while also offering my help anyone that needed it. In two interviews I was asked what I would do if I was got into a confrontation or disagreement with a coworker or if an LPN or CNA I was supervising was not doing their job effectively. I said I would again handle it professionally, see if I could work it out with the individual, find out if there was a reason behind it, and if I couldn't solve it myself I would go up the chain of command. I think they may have asked me one more, but I can't remember it at the moment. Just relax, do some research on the place you're applying to, and how their organization work and you'll do great!!!
Oh and I got job offers for both interviews
Just a piece of advice:
If the hospital you are applying at has an open house or any other activity where you can meet some of the hiring coordinators or nurse managers....GO!!!! I went to the open house at Seton and just by chance the hiring coordinator and her assistant was THRILLED to have a student from my nursing school. It totally blew my mind. I kept asking myself, "why the heck do they want someone from my school so bad?" I mean her eyes just lit up when I told her the school I was from.
I promise you, you never know what can happen. At that open house I met some of the nurse managers on the unit I wanted to be on and had the opportunity to put my resume in their hands. That was invaluable as the nurse managers, not the hiring coordinators are really the ones that hire you. Remember that, the managers hire you not the hr people. Do whatever you can to meet with the manager on the unit you want b/c hr just sees you as a number. Dont be shy, DO IT! Its too competitive to be shy.
The only ppl that called me for an interview were the ppl that I put the resume in their hands. If you really want the job, dont let that opportunity pass by. Look on their website and see if they have an open house or job fair or something. Or simply call the hospital and ask to speak to the nurse recruiter. YOU WANT TO MEET THE MANAGER (!), not just give your social to HR. The managers in my case remembered my face and gave me a call. Be a punk if you want, but the ppl who are serious are taking all the jobs. Its up to you.
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